Healthcare Provider Details

I. General information

NPI: 1932146941
Provider Name (Legal Business Name): SOUTHEAST HUMAN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 9TH AVE S
FARGO ND
58103-2350
US

IV. Provider business mailing address

2624 9TH AVE S
FARGO ND
58103-2350
US

V. Phone/Fax

Practice location:
  • Phone: 701-298-4500
  • Fax: 701-298-4400
Mailing address:
  • Phone: 701-298-4500
  • Fax: 701-298-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1015
License Number StateND

VIII. Authorized Official

Name: JEFFREY J STENSETH
Title or Position: DIRECTOR
Credential:
Phone: 701-298-4500